Taiji Tsukamoto

Decrease in incidence of surgical site infections in contemporary series of patients with radical cystectomy

We previously reported that the incidence of surgical site infection (SSI) after radical cystectomy was 33% between January 1996 and December 2003 at Sapporo Medical University Hospital. Base on that result, we modified perioperative management for surgical wounds after January 2004. The modifications included the method of suturing and standardization of the period for removal of closed drains and surgical dressings. This study compared the incidence of SSI between the former and latter periods, and assessed risk factors for SSI. The study consisted of 109 patients between January 1996 and December 2003 (Group A), and 104 patients between January 2004 and December 2007 (Group B), who underwent radical cystectomy and urinary diversion or reconstruction. The incidence of SSI was reduced from 32.1% in Group A to 18.2% in Group B (pxa0=xa00.027). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from SSI wounds in 40.0% of patients in Group A and 42.1% of those in Group B. Preoperative MRSA bacteriuria was the only risk factor for SSI in both groups. The incidences of SSI in patients who had such bacteriuria were 45.4% in Group A and 50.0% in Group B. Modification of perioperative management for the surgical wound was partly responsible for the reduction of the incidence of SSI. In conclusion, MRSA is still the main isolated pathogen of SSI after radical cystectomy and this clinical problem remains a challenge to urologists. Effective countermeasures are needed for MRSA bacteriuria involved in the development of SSI.

Multicenter Phase II Trial of S-1 in Patients With Cytokine-Refractory Metastatic Renal Cell Carcinoma

PURPOSEnThis phase II multicenter trial was conducted to evaluate the activity and safety of S-1 in Japanese patients with metastatic renal cell carcinoma (mRCC). We also examined the relation between response and mRNA expression levels of enzymes involved in the metabolism of fluorouracil (FU).nnnMETHODSnPatients with mRCC who had received nephrectomy in whom cytokine-based immunotherapy was ineffective or contraindicated were studied. S-1 was administered orally at 80-, 100-, or 120-mg daily, assigned according to body surface area, on days 1 to 28 of a 42-day cycle. The primary end point was the objective response rate. The mRNA expression levels of FU-related enzymes were measured by reverse-transcriptase polymerase chain reaction in formalin-fixed, paraffin-embedded specimens of tumors obtained at nephrectomy.nnnRESULTSnA total of 45 eligible patients were enrolled. Eleven (24.4%) of 45 patients had partial responses to S-1, and 28 (62.2%) had stable disease. Median progression-free survival was 9.2 months. The severity of most adverse events was mild to moderate. The most common grade 3/4 drug-related adverse events were neutropenia (8.9%) and anorexia (8.9%). The expression level of thymidylate synthase (TS) mRNA was significantly lower in patients who responded to treatment (t-test, P = .048), and progression-free survival was significantly longer in patients whose TS mRNA expression levels were below the median value, as compared with those with higher levels (log-rank test, P = .006).nnnCONCLUSIONnS-1 is active against cytokine-refractory mRCC. Quantification of TS mRNA levels in tumors before treatment may facilitate prediction of the response of mRCC to S-1.

Baseline erectile function alters the cavernous nerve quantity and distribution around the prostate.

PURPOSEnWe clarified the distribution of neuronal nitric oxide synthase positive nerve fibers around the prostate and factors contributing to fiber quantity.nnnMATERIALS AND METHODSnWe investigated 46 hemispheres of 23 nonnerve sparing radical prostatectomy specimens from patients with available preoperative International Index of Erectile Function and maximum penile circumferential change data. We performed immunohistochemical staining with neuronal nitric oxide synthase antibody, and divided the prostatic hemisphere into 6 zones to assess the distribution of neuronal nitric oxide synthase positive nerve fibers at the apex, midportion and base of the prostate. Multivariate analysis of the quantity of overall neuronal nitric oxide synthase positive nerve fibers used the variables of specimen weight, patient age, body mass index, International Index of Erectile Function and maximum penile circumferential change. A maximum penile circumferential change of 20 mm or less was considered objective erectile dysfunction.nnnRESULTSnMedian patient age was 68 years (range 57 to 74). Median International Index of Erectile Function-erectile function domain score was 12 (range 0 to 24) and median maximum penile circumferential change was 25.0 mm (range 2.70 to 38.3). Of the neuronal nitric oxide synthase positive nerve fibers 65% were distributed in a 3 to 5 oclock sextant (p <0.001). Logistic regression analysis revealed that maximum penile circumferential change was the single significant variable (p = 0.019). The fiber count was greater in the objective erectile dysfunction group (median 1,500, range 382 to 2,760) than in the nonerectile dysfunction group (median 649, range 156 to 2,916) (p = 0.009). The fiber count was significantly different between the 2 groups in the 3 to 6 oclock area, especially at the apex.nnnCONCLUSIONSnBaseline erectile function greatly impacts cavernous nerve quantity and distribution. Cavernous nerve preservation in the neurovascular bundle, especially at the apex, is still essential for patients with erectile dysfunction.

Urodynamic effects of solifenacin in untreated female patients with symptomatic overactive bladder

Objectives:u2003 To investigate the urodynamic effects of solifenacin in untreated female patients with symptomatic overactive bladder (OAB).

Efficacy of treatment with carbapenems and third-generation cephalosporins for patients with febrile complicated pyelonephritis.

The purpose of this study was to clarify the clinical relevance of carbapenem and third-generation cephalosporin treatment for febrile complicated pyelonephritis, which often leads to urosepsis. Parenteral antimicrobial treatment with a carbapenem or third-generation cephalosporin was administered to febrile patients and the treatment was switched to oral antimicrobial agents after they became afebrile. In principle, the duration of the course of antimicrobial chemotherapy was limited to a total of 14 days. Clinically, the success rates were 97.3% in the carbapenem group and 96.0% in the third-generation cephalosporin group. For microbiological efficacy, the success rates were 89.2% in the carbapenem group and 92.0% in the third-generation cephalosporin group. There were no serious adverse events in the course of the study. The treatment regimen with a carbapenem or a third-generation cephalosporin was highly effective for patients with febrile complicated pyelonephritis and was well tolerated. Either of these regimens could become one of the standard treatments for patients with febrile complicated pyelonephritis.

The Add-On Effect of Solifenacin for Patients with Remaining Overactive Bladder after Treatment with Tamsulosin for Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Obstruction

Objectives. To investigate the add-on effect of solifenacin for Japanese men with remaining overactive bladder (OAB) symptoms after tamsulosin monotherapy for lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO) in real-life clinical practice. Methods. Patients aged ≥ 50 having remaining OAB symptoms (≥ 3 of OAB symptom score (OABSS) with ≥2 of urgency score) after at least 4 weeks treatment by 0.2u2009mg of tamsulosin for BPO/LUTS received 2.5 or 5.0u2009mg of solifenacin for 12 weeks. The International Prostate Symptom Score (IPSS), QOL index and OABSS, maximum flow rate (Qmax) and postvoid residual urine volume (PVR) were determined. Results. A total of 48 patients (mean age 72.5 years) completed the study. There were significant improvement in IPSS (15.1 to 11.2) and QOL index (4.2 to 3.0) by add-on of solifenacin. Although the IPSS storage symptom score was significantly improved, there were no changes observed in the IPSS voiding symptom score. The OABSS showed significant improvement (8.0 to 4.8). No changes were observed in Qmax and PVR. Conclusions. Under the supervision of an experienced urologist, the additional administration of solifenacin to patients with BPO/LUTS treated with tamsulosin, is effective in controlling remaining OAB symptoms.

Clinical safety and feasibility of a newly developed, simple algorithm for decision-making on neurovascular bundle preservation in radical prostatectomy.

OBJECTIVEnWe investigated the clinical safety and feasibility of an algorithm we developed for the decision-making on neurovascular bundle preservation in radical prostatectomy to decrease the incidence of positive surgical margins.nnnMETHODSnWe prospectively applied our algorithm to 82 patients (164 prostate sides) with clinically localized prostate cancer who underwent radical prostatectomy at our institution between October 2004 and September 2006. The algorithm was developed using the apical core characteristics, clinical T stage, preoperative prostate-specific antigen level and Gleason sum. All prostate sides were divided into two groups by the algorithm: 115 sides (70.1%) were qualified for neurovascular bundle preservation (favorable algorithm side group) and 49 sides (29.9%) for non-neurovascular bundle preservation (unfavorable algorithm side group).nnnRESULTSnMedian patient age was 66 years (range: 52-77) and median prostate-specific antigen was 7.1 ng/ml (range: 1.4-29.6). Overall, a positive surgical margin was observed in 23 sides (14.0%). The incidence of positive surgical margins at the apex was significantly correlated with the maximal diameter of the tumor in the apex (P < 0.001). The incidence of positive surgical margins was 8.7% in the favorable algorithm group, whereas it was 26.5% in the unfavorable algorithm group (P = 0.003). When this algorithm was combined with surgeons intraoperative assessments, the incidence of positive surgical margins was 2.1% in neurovascular bundle preservation sides, compared with 25.0% in non-neurovascular bundle preservation sides (P = 0.002).nnnCONCLUSIONSnThis simple algorithm is safe and feasible for the decision-making on neurovascular bundle preservation from the aspect of cancer control in radical prostatectomy patients.

Late Recurrence and Second Primary Malignancy among 139 Patients with Germ Cell Tumors: Long-term Outcome of the Disease in a Single-center Experience

Objective We retrospectively evaluated long-term oncological outcomes in patients with germ cell tumors (GCTs) primarily treated at our institution and assessed late recurrence and second primary malignancies. Methods This study included a total of 139 males with newly diagnosed GCTs of the testis or extragonadal origin who received treatment, including surgery, chemotherapy and radiation therapy, at our hospital between 1980 and 2005. We reviewed late recurrence that occurred at least 2 years after the initial disease-free status and secondary malignancies as well as oncological outcomes. Results In patients with seminoma, 5-year progression-free survival and cause-specific survival rates were 87.2% and 100% for Stage I, 88.9% and 100% for Stage II, and 50.0% and 50.0% for Stage III, respectively, whereas in those with non-seminomatous GCTs, they were 79.1% and 96.3% for Stage I, 89.5% and 89.4% for Stage II, and 85.7% and 78.4% for Stage III, respectively. Late recurrence was found in five (3.6%) patients and all of them responded to salvage treatment and achieved disease-free status. Second primary hematological neoplasms occurred in three (2.2%), although they had a long-term free of the primary disease. All died of the second primary disease. Conclusions Late recurrence was successfully managed with appropriate treatments, although its incidence was not negligible. Periodic follow-up may be necessary for >5 years in patients with GCTs for early detection of late recurrence. In addition, care should be taken to watch for the development of life-threatening second primary malignant disease during long-term follow-up.

Is T1G3 Bladder Cancer Having a Definite Muscle Layer in TUR Specimens a Highly Progressive Disease

OBJECTIVEnPatients with T1G3 bladder cancer are at high risk of progression to muscle-invasive cancer, and early cystectomy is considered as a treatment option in this particular situation. On the other hand, understaging of T1G3 bladder cancer has been gradually proven as second or repeat transurethral resection (TUR) has been widely applied. To evaluate the real rate of progression, we investigated the prognosis of T1G3 bladder cancer in which a muscle layer was histologically confirmed in the TUR specimens.nnnMETHODSnWe retrospectively reviewed 48 patients with primary T1G3 bladder cancer in which a muscle layer in the TUR specimens was confirmed between 1990 and 2006 in our institute. We investigated recurrence and progression in 45 patients, excluding 3 who were immediately treated with radical cystectomy. Fifteen and 12 patients received intravesical treatment with bacillus Calmette-Guérin (BCG) and anticancer agents just after TUR, respectively. The remaining 18 did not have any such treatment.nnnRESULTSnRecurrence and progression were observed in 21 (47%) and 3 patients (6.7%), respectively, during a median follow-up period of 42.1 months. The 3-year recurrence-free and progression-free survival rates were 54% and 91%, respectively. No significant differences were observed in the rates between the patients with and without BCG treatment in the study.nnnCONCLUSIONSnThere is a possibility that the progression rate in patients with T1G3 bladder cancer is not as high as previously reported when only patients whose muscle layer was histologically confirmed were analyzed. An adequate technique for TUR that unmistakably collects the muscle layer may be important to predict the outcome accurately.

Clinical relevance of single administration of prophylactic antimicrobial agents against febrile events after removal of ureteral stents for patients with urinary diversion or reconstruction.

Objective:u2003 To assess the efficacy of antimicrobial prophylaxis when removing ureteral stents after urinary diversion or reconstruction and to establish the most appropriate prophylactic protocol to prevent febrile events.